Spain

In 2009, notable differences in HIV prevalence were observed between male and female sex workers; these groups had prevalence levels of 0.9% and 21.2%, respectively. A 2005 study of prevalence of sexually-transmitted diseases among female sex workers in Spain found that 95.5% of these sex workers used condoms during vaginal sex with clients, however only 12.4 % of female sex workers used condoms with their regular partners. 26% of the 400 women interviewed for the study were from Africa.

In Spain, 12.2 % of male sex workers are HIV-positive.  There are no specific preventive programs directed to this population group, which may partially be covered by programs aimed at female sex workers or homosexual men. Prevalence among male sex workers in Spain has not been well studied. This group requires more targeted interventions to reduce transmission.

Migration can increase vulnerability to HIV and has been identified as an independent risk factor for HIV in some regions. Undocumented migrants face obstacles to accessing health care as a result of social exclusion, lack of social protection, adverse socioeconomic conditions and health policies that can hamper timely HIV diagnosis and access to HIV treatments.

There are an estimated 600,000 undocumented immigrants in Spain, one of the highest rates in the European Union, despite immigration processes that are deemed to be ‘favourable.’ Disparities in health service use by migrants in Spain may be related to lack of familiarity with the health system, doctor ­patient communication issues, or differences in risk perception and health seeking behaviors.

Spain provides universal publicly- funded health care to all residents, free of charge. In 2012, the Spanish government passed a new legislation whereby undocumented migrants older than 18 (except pregnant women, children and migrants needing access to emergency wards in hospitals) were no longer eligible to receive state funded health care. The government established an insurance scheme so that those excluded from access to publicly funded healthcare could buy health care for an annual premium of €710. It was estimated that 800,000 migrants had their health cards removed and only 500 migrants signed up for the special insurance scheme.

Less than three years after the legislation was passed, the government repealed it because there was a recognition that Spain’s limited health care resources were being used more intensely to deal with accidents and care in emergency wards. To access health care services, all residents, including migrants (irrespective of their migratory status) must be registered in a municipality to receive a health card. Undocumented migrants in Spain are entitled to access the same range of services as nationals as long as they met certain pre-conditions, such as proof of identity or residence. However, undocumented migrants may be reluctant to register to receive access to health services due to their legal status in the country.

HIV treatment in Spain is provided exclusively through pharmaceutical services in hospitals. Care is provided by large hospitals through a specific infectious diseases unit and in smaller hospitals by the internal medicine service.

Though the number of AIDS cases in most EU countries have declined from the 1990’s onwards (due to antiretroviral medicines), the same decline has not been observed in migrant populations. This reflects late diagnosis of HIV and poorer access to and uptake of antiretroviral medicines. HIV-specific barriers to testing and care include insufficient knowledge of HIV, stigmatization, low risk perception, lack of knowledge about testing sites and concerns about confidentiality.

Specific barriers that have hampered migrants and ethnic minorities from accessing HIV services have included their legal status, high unemployment rates, poverty, and low socioeconomic status. Studies from Spain reveal concerns about the ramifications of receiving an HIV positive-test have posed as a central barrier to HIV testing.

Spain does not require that an individual be tested for HIV upon entry into the country nor does it bar entry to migrants with HIV. However, those that are suspected of having an infectious disease may be obliged to undergo medical examination within the first three months after arrival in Spain (free of charge). Given that migrants with HIV may face social exclusion and stigma, navigating health care services may prove to be difficult. Further, migrants may be reluctant to access HIV health care services for perceived fears of negative consequences.

Immigrants are disproportionately employed in jobs in the construction, agriculture and hotel and domestic services sectors in Spain. Jobs in these sectors pay low wages and carry greater workplace risks and hazards. As such, policy interventions aimed at increasing access to health care and health seeking behaviour as well as pro-employment and social support policies to provide fair wages and appropriate protection for those that are employed, unemployed and in precarious work situations must be developed.

Policy-making on migration has generally been developed in sector siloes. Immigration and labour policies rarely include the health sector. Spain repealed access to healthcare for undocumented migrants in 2012 only to reinstate it in 2015 due to increased accidents and emergency room visits by migrants. This is an example whereby short sighted health policies affect not only the health of migrants but also health resource utilization and thereby access to health care for other residents.

The share of sub-Saharan African migrants that have moved outside Africa for economic reasons has increased six-fold from 1 million in 1990 to 6 million in 2013. It is projected that sub-Saharan migrant population will continue to increase. About 85% of the sub-Saharan African diaspora in the rest of the world is in countries belonging to the Organization for Economic Cooperation and Development (OECD). Given that migrants from sub-Saharan African countries mainly migrate for economic opportunities, host countries, including Spain must develop policies that are integrated across the heath, labour and migration sphere to provide appropriate protections to migrants.